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Management of a Mangled Ischemic Nearly-Amputated Hand Following a 60-ton Press Injury
Jacob A. Vincent PhD, Spencer R. Anderson MD, Sunishka M. Wimalawansa MD MBA.
Dept. of Orthopedic and Plastic Surgery, Wright State University
2018-01-30
Presenter: Jacob A. Vincent
Affidavit:
Both the resident and medical student have contributed equally to the production of this paper, with case provided by the associate professor.
Director Name: R. Michael Johnson, MD
Author Category: Medical Student
Presentation Category: Clinical
Abstract Category: Hand
Purpose: Crushing mangled hand injuries are very challenging cases, warranting multiple staged complex procedures. Initial steps aim to maximize reconstructive potential and overall functional capacity. Here, we discuss pre, intra and post-operative management, all in effort to maximize functional recovery.
Methods: Retrospective chart review was performed, with number of operations, final range of motion and function as outcome measures.
Results: A 57-year-old male presented with a work-related right hand severe crush injury by a 60-ton press machine with devascularization. Due to the severity of the injury and extensive comminuted skeletal deformities, bony structures were first stabilized using pins and external fixation, beginning with the carpus. Following restoration and stabilization of length, revascularization was performed via vein grafting from the forearm to the 3rd common digital artery and reduction of the thumb. The index and small fingers were non-salvageable and used as fillet flaps for coverage. The ring finger and palmar skin subsequently demarcated, requiring ring finger revision amputation and pedicled abdominal flap resurfacing. Thumb and long finger non-unions required bone grafting. Next steps include joint releases with tenolyses to restore function, and advanced wrist-powered prostheses to augment grip.
Conclusion: Mangled severe hand crush injuries warrant immediate treatment to stabilize and revascularize, identify salvageable tissue, debride the rest, and reconstruct with all efforts focused upon establishing maximal functionality. It is critical to recognize that these cases will likely show delayed post-operative soft tissue demarcation, and therefore attempts should be made to stage and delay definitive soft tissue coverage procedures.
